Accepting trans identity: a note of caution
Dr Pravin Thevasathan.
During my time as editor of the CMQ, some articles have attracted a lot of attention. One such is the August 2017 article by Dr David Jones entitled "The American College of Pediatricians statement of Gender Ideology: a note of caution." 
Over the years, I have come to appreciate the tremendous contribution Dr Jones has made in the field of Catholic bioethics. As for the article, there was much I agreed with, much that I did not. I asked for a response from the American College of Pediatricians and this was published in the following issue. 
Since then, Dr Jones has given an interview on the same topic and this has been published by Crux Now in a piece entitled "Ethicist says Church teaching on gender 'not incompatible' with accepting trans identity."  Again, there is much in it to like. We do need to listen to people with gender dysphoria and understand their suﬀering. It was moving to read how much this act of listening means to them. As clinicians, we should never discriminate against them.
But what does the Catholic Church teach on the specific issue of gender reassignment surgery? As Dr Jones notes, this is a work in progress. However, we can learn a good deal from what has already been said. Dr Jones notes that moral theologians are divided between those who characterize it as mutilation causing direct harm to the body and therefore incompatible with Catholic medical ethics and those who argue such surgery could be considered justifiable, if it helps alleviate the extreme distress of gender dysphoria. Dr Jones continues: "However, typically the second group of theologians have cast doubt on whether such surgery is eﬀective in providing long-term relief." His own view is that "surgery may alleviate the suﬀering of some patients. However, I cannot see how gender reassignment surgery, when this causes sterility, is compatible with the ethical principles of Catholic traditions."
This is indeed a cautiously proposed and nuanced position. But is it in line with orthodox Catholic teaching? As Dr Jones knows well enough from his excellent contributions to the ethics of euthanasia, slippery slopes are real and hard cases make bad law.
For an orthodox Catholic viewpoint, I turn to the always helpful Manual of Catholic Medical Ethics: "Sex change is not an acceptable response to transsexuality...The diﬃculty in the case of a person who requests a sex change is psychological, and the diﬃculty cannot be resolved by medical intervention or surgical operations. Studies of the results of these interventions also show that the transsexuals' problems are often not resolved by sex change, and that other problems arise in their stead...Roman Catholic institutions and health-care personnel should therefore not cooperate in these types of treatment." 
According to the Manual, the fundamental root of the problem is to be found in the view that "biological sex can, in principle, be adjusted to the gender role one has chosen. In reality, however, the body, and therefore being a man or a woman, is an intrinsic dimension with an intrinsic value over which the human person does not have a right of determination. Sexuality is clearly not only a biological fact but it also has a mental, social and spiritual dimension. These dimensions are not separate from biological sexuality, however, but rooted in it. " What is being criticized here is the dualistic notion that our bodies and minds are disjointed, separate entities, as well as the view that our biological sex has no intrinsic value calling for respect.
Dr Jones states that we should not assume that "someone expressing a deep-seated sense of gender identity is doing something sinful or objectively disordered. On the contrary, the person may be accepting his or her gender identity as something given by God." But can the Church endorse a view that an inclination that often leads the way to what it considers sinful behavior (sterilising surgery, non-marital sexual acts) is "given by God?" Even if the inclination does not lead to sinful behaviour in some, is it really a healthy inclination they should celebrate as God-given? Some trans people would themselves reject that approach.
Dr Jones favorably observes that Pope Francis has referred to a person who was born a girl but now wishes to be considered a man as "he, who had been she, but is he." Pope Francis loves meeting people and oﬀering them homely, pastoral snippets. Many of these are excellent. None magisterial.
Alexander Pruss is Professor of philosophy at Baylor University, Texas, and author of the brilliant book One Body: An Essay in Christian Sexual Ethics.  I asked him to comment on the Jones interview and he kindly sent the following:
“There is a conceptual distinction between sex and gender. Sex is to a significant degree a biological category, a category applicable within at least all mammalian species, including humans. Gender, as the term is commonly used in our time, is a more fluid category having to do with social - and self-identity. I think the Catholic tradition has tended to use the words "man" and "woman", rather than to talk of "sex" or "gender". This raises the important question whether "man" and "woman" in the Catholic tradition should be seen as referring to sex or to gender (in our current social usage).
I will argue that there is good reason in the Catholic tradition to think that whatever "man" and "woman" refer to, it is a characteristic beyond our power to change. Doctrinally, there are two ways to this conclusion: reflection on marriage and reflection on the priesthood. The Church teaches unambiguously that marriage must be between a man and a woman, and that the Church is only authorized to ordain men. These are, of course, highly controversial claims, and an argument based on them will not convince many who are not faith-ful Catholic. But I hope they would be convincing to Dr. Jones.
For suppose it were possible for a man to become a woman and vice versa. Then it would be possible for two faithful Catholic men who love each other deeply and want to be married to each other to fulfill that desire, by having one of them first become a woman with sexual organs capable of consummation (whether current sex-reassignment surgery can produce this capability or whether further medical progress would be needed is not directly relevant to my argument), then sacramentally marry the other and consummate the marriage, and then return to being a man. (This process might be very diﬃcult psychologically, but people do do very hard things for love!) Since it is Catholic teaching that a consummated sacramental marriage can only be ended by death, the result would be that the two men are married to each other. Similarly, a woman could become a man, then be ordained, and then return to being a woman. Again, it is Catholic teaching that ordination can only be terminated by death, so this woman would indeed be a priest.
But it seems strange to think that while marriage must be between a man and a woman and only men are to be ordained, we could circumvent this in the above way. It would be a bizarre view that a man can be validly and licitly married to a man and a woman can legitimately be a priest but God only makes this possible through a complex pair of diﬃcult man-woman transitions, perhaps involving surgeries.
I conclude that these transitions are impossible: a man cannot become a woman and a woman cannot become a man, where the words "man" and "woman" are used in the sense that the Catholic tradition typically uses them. This suggests that the words "man" and "woman" in the Catholic tradition align more closely with sex than with gender in contemporary parlance.
This still leaves a pastorally important question. If gender is a matter of social- and self-identification, could it be morally licit to live a life where one's gender does not neatly align with whether one is biologically and, we might say, metaphysically a man or a woman? Of course, marriage and ordination would have to align with the metaphysics: only men and women can marry each other and only men can be ordained. But could a chastely unmarried and unordained person, say, live a life of a gender identity other than the one matching the metaphysics? I worry somewhat that there could be a kind of self-deceit there, but matters are not so clear.
Perhaps an easier question is whether one needs to have a gender identity at all. It is an objective fact that my eyes are blue. But I do not live a life of identification as a "blue-eyed person". The color of my eyes is a fact that I will truthfully admit to when filling out government paperwork, but it is of very little significance to me. It seems to me to be compatible with settled Catholic doctrine that a chastely unmarried lay person could licitly live a life where their objectively being a man or a woman is of as little significance outside the doctor's oﬃce as my eye color is to me. That said, such a view, while not unorthodox, may not be as attractive as John Paul II's personalist insistence that our maleness and femaleness are important reminders of our nature as self-givers, as beings-for-others.”
We live in a fallen world where there is much confusion, disharmony and human suﬀering not only in regard to our human inclinations. Ethical decision making can often be messy and challenging. But Saint John Paul’s “personalist insistence” is in perfect harmony with God’s basic plan for creation as laid out in the Book of Genesis and it is therefore diﬃcult to understand why Dr Jones believes that the teaching on sexual complementarity “need not be incompatible with aﬃrming the gender identity of trans people.” The trans person’s very genuine feelings can be negotiated in ethical ways, without the person or others seeing these experiences as something positive reflecting some deep truth – something that defines him or her. What should be valued is the biological sex, not the person’s diﬃculty accepting that sex. It is fitting to give the last words to the first Book: “Male and female He created them.” (Gen1:27)
- Jones D (2017). The American College of Pediatricians statement on “gender ideology”: a note of caution. Catholic Medical Quarterly 67 (3), 11-14. http://www.cmq.org.uk/CMQ/2017/Aug/Comment-on-gender-ideology.html
- Cretella M. The american college of pediatricians statement on “gender ideology”: a note of caution. Catholic Medical Quarterly Volume 67(4) November 2017. http://www.cmq.org.uk/CMQ/2017/Nov/letters-gender-identity.html
- Charles C. Camosy, Ethicist says Church teaching on gender ‘not incompatible’ with accepting trans identity. Crux Now, 26 July, 2018, https://cruxnow.com/interviews/2018/07/ethicist-says-church-teaching-on-gender-not-incompatible-with-accepting-trans-identity/
- Eijk, Hendriks, Raymakers and Fleming, Manual of Catholic Medical Ethics, Connor Court Publishing, 2014, pg.464.
- Eijk, pg.463/p>
- Pruss A. One Body: An Essay in Christian Sexual Ethics. Published by: University of Notre Dame Press. 2013. https://doi.org/10.2307/j.ctvpj7d0g